Healthcare Provider Details

I. General information

NPI: 1346686078
Provider Name (Legal Business Name): JENNIFER A. LOGAN PSY.D, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CHANGEBRIDGE RD BLDG B32
MONTVILLE NJ
07045-8805
US

IV. Provider business mailing address

170 CHANGEBRIDGE RD UNIT B3-2
MONTVILLE NJ
07045
US

V. Phone/Fax

Practice location:
  • Phone: 551-399-9660
  • Fax:
Mailing address:
  • Phone: 551-399-9660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00328400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: